You are here

Inspection Summary


Overall summary & rating

Good

Updated 13 September 2017

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Grange Street Surgery on 17 May 2017. We identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided well-led services. Consequently the practice was rated as requires improvement for providing well-led services. The focused report from the 17 May 2017 inspection can be found by selecting the ‘all reports’ link for Grange Street Surgery on our website at www.cqc.org.uk.

After the focused inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to;

  • Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014

- Good governance.

The areas identified as requiring improvement during our inspection in May 2017 were as follows:

  • Ensure plans of action to control and resolve the risks identified by the health and safety and Legionella risk assessments are completed.
  • Ensure that the Legionella management policy is adapted to the specific needs and requirements of the practice.
  • Ensure the governance arrangements in place provide staff with a clear understanding as to who is responsible for managing and responding to health and safety related issues and risks.

In addition, we told the provider they should:

  • Ensure that all clinical staff are participating in the practice’s programme of online essential training (e-learning).

We carried out an announced focused inspection on 30 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches of regulation that we identified in our previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key finding on this focused inspection was that the practice had made improvements since our previous inspection and were now meeting the regulation that had previously been breached.

The practice is now rated as good for providing well-led services.

On this inspection we found:

  • The governance arrangements at the practice supported the provision of a safe work place and patient environment.
  • Action was taken or in progress to respond to the risks identified and the improvements required by the health and safety review and Legionella risk assessment.
  • The Legionella management policy was specific to the needs and requirements of the practice.
  • Staff demonstrated a clear understanding as to who was responsible for managing and responding to health and safety related issues and risks.

Additionally where we previously told the practice they should make improvements our key finding was as follows:

  • Clinical staff were participating in the practice’s programme of online essential training (e-learning).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 16 December 2016

At our comprehensive inspection on 20 January 2016, we identified breaches of legal requirements. Improvements were needed to processes and procedures to ensure the practice provided safe services. During our focused inspection on 30 September 2016 we found the provider had taken action to improve and the practice is rated as good for providing safe services.

  • Systems designed to assess the risk of and to prevent, detect and control the spread of infection were in place and adhered to.

  • Systems were in place to ensure that staff employed at the practice received the appropriate recruitment checks.

  • There were sufficient systems and processes in place to monitor and address risks to patients and staff. However, there was not yet an action plan in place to address the issues identified in a recently completed health and safety risk assessment. Also, an updated Legionella risk assessment was yet to be completed and the Legionella management policy was not adapted to the specific needs and requirements of the practice. We found that plans were in place to address these issues.

  • Suitable arrangements were in place for the practice to respond to emergencies and major incidents.

Effective

Good

Updated 5 June 2017

At our focused inspection on 30 September 2016, we identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided effective services. During our focused inspection on 17 May 2017 we found the provider had taken action to improve and the practice is rated as good for providing effective services.

  • There was a formal and documented induction programme in place for newly appointed staff that ensured they had a comprehensive understanding of practice processes and procedures, including essential training requirements.
  • A system was in place to ensure staff completed the essential training relevant to their roles. However, the GPs at the practice were not participating in the e-learning training.

  • Sufficient systems were in place to ensure all staff received regular supervision and an appropriate appraisal of their skills, abilities and development requirements.

Caring

Good

Updated 6 April 2016

The practice is rated as good for providing caring services.

  • Data from the National GP Patient Survey from January 2016 showed patients rated the practice higher than local and national averages for most aspects of care.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 6 April 2016

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.
  • Data from the National GP Patient Survey from January 2016 showed patients rated the practice better than local and national averages for most aspects of access to the practice. Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 13 September 2017

At our focused inspection on 17 May 2017, we identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided well-led services. During our focused inspection on 30 August 2017 we found the provider had taken action to improve and the practice is rated as good for providing well-led services.

  • The governance arrangements at the practice supported the provision of a safe work place and patient environment.
  • Action was taken or in progress to respond to the risks identified and the improvements required by the health and safety review and Legionella risk assessment.
  • The Legionella management policy was specific to the needs and requirements of the practice.
  • Staff demonstrated a clear understanding as to who was responsible for managing and responding to health and safety related issues and risks.
  • Clinical staff were participating in the practice’s programme of online essential training (e-learning).
Checks on specific services

People with long term conditions

Good

Updated 6 April 2016

The practice is rated as good for the care of people with long-term conditions.

  • There were nurse led clinics for chronic disease management and patients at risk of hospital admission were identified as a priority.
  • Performance for diabetes related indicators was comparable to the CCG and national averages. The practice achieved 83% of the points available compared to the CCG average of 91% and the national average of 89%.
  • All newly diagnosed patients with diabetes were managed in line with an agreed pathway.
  • Longer appointments and home visits were available when needed.
  • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GPs worked with relevant health and care professionals to deliver a multi-disciplinary package of care.

Families, children and young people

Good

Updated 6 April 2016

The practice is rated as good for the care of families, children and young people.

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.
  • 76% of patients with asthma, on the register, had a review in the preceding 12 months. This was comparable to the CCG average of 76% and the national average of 75%.
  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
  • The practice’s uptake for the cervical screening programme was 84% which was comparable to the CCG average of 83% and the national average of 82%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • There were six week post-natal checks for mothers and their children.
  • A range of contraceptive and family planning services were available.

Older people

Good

Updated 6 April 2016

The practice is rated as good for the care of older people.

  • The practice offered proactive, personalised care to meet the needs of the older people in its population.
  • The practice was responsive to the needs of older people and offered home visits and urgent appointments for those with enhanced needs.
  • Older people had access to targeted immunisations such as the flu vaccine.
  • GPs and nurses completed regular visits to local nursing homes to ensure continuity of care for those patients.

Working age people (including those recently retired and students)

Good

Updated 6 April 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

  • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
  • The practice offered online services such as appointment booking and repeat prescriptions as well as a full range of health promotion and screening that reflects the needs for this age group.
  • There was additional out of working hours access to meet the needs of working age patients. There was extended opening from 7am every Tuesday and from 8.30am to 10.30am one in every four Saturdays.

People experiencing poor mental health (including people with dementia)

Good

Updated 6 April 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • 95% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months. This was above the CCG average of 85% and the national average of 84%.
  • Performance for mental health related indicators was similar to the CCG and national averages. The practice achieved 89% of the points available compared to the CCG average of 96% and the national average of 93%.
  • The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia.
  • The practice carried out advance care planning for patients with dementia.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.
  • There was a GP lead for mental health.
  • Mental health trust well-being workers and NHS counsellors were based at the practice every week.

People whose circumstances may make them vulnerable

Good

Updated 6 April 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
  • The practice offered longer appointments for patients with a learning disability.
  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.
  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
  • Additional information was available for patients who were identified as carers and there was a nominated staff lead for these patients.
  • A community navigator (a source of advice and practical support relating to health and social well-being) was based at the practice once each month.